Provider Demographics
NPI:1134200389
Name:JACKSON, SHARON RUTH
Entity type:Individual
Prefix:MRS
First Name:SHARON
Middle Name:RUTH
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4801 LAKESHORE CT
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-2828
Mailing Address - Country:US
Mailing Address - Phone:972-206-0111
Mailing Address - Fax:972-206-0111
Practice Address - Street 1:2100 N. HWY 360
Practice Address - Street 2:SUITE 1704
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75050-1062
Practice Address - Country:US
Practice Address - Phone:972-206-0111
Practice Address - Fax:972-206-0111
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0058191171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0432380001Medicare NSC